HospitalInspections.org

Based on interview, policy review and medical record review it was determined the hospital failed to maintain an accurate and complete medical record for 1 of 7 sampled patients (Patient 5). Findings include:

During the survey a sample of patient medical records was selected for review. That review revealed that the medical record for Patient 5 had not been maintained in an accurate and complete manner as required by rule, and by hospital policy "Nursing Documentation Standards."

Hospital policy "Nursing Documentation Standards" indicated that "a client's medical record is an account of...health history, current health status, treatment and progress." That policy directed staff to "meet the medical and legal standards throughout the documentation process."

Nursing staff was to complete a shift assessment within "two hours of the beginning of each shift" and reassess with "any significant change in patient status." In addition a Nursing Plan of Care was to be updated each shift and was to "identify problems and indicate whether progress has been made in meeting objectives." The policy specifically directed staff that "a patient who requires restraints must have restraints listed as a problem in the care plan."

Review of Patient 5's medical record and interview with facility staff determined that the hospital failed to implement hospital policy "Nursing Documentation Standards" while providing his/her patient care on 9/29/11.

According to hospital records Patient 5 had been admitted through the Emergency Department on 9/25/11 with a bowel obstruction, and referred to Physician A for treatment. Physician A performed a surgical procedure on 9/28/11 and Patient 5 returned to a nursing unit for routine postoperative care.

Hospital "Multidisciplinary Progress Notes" and "Shift Assessments" of 9/29/11 reflected that Patient 5 received routine care and had an uneventful day. However, a review of the 9/29/11 "Physician Orders" for Patient 5 reflect that at 12:35 pm Physician A provided a telephone order "may use restraints, may use sitter."

There is no documentation in the nursing care record to indicate what would have prompted the request for the restraint order, or necessitated such an intervention. There is no indication in the record of any type of change in condition, medication reaction, change in behavior, incident or event. Patient 5's "Shift Assessment" was not updated at that time, and no additions were made to the Plan of Care.

At 5:10 pm Physician A noted "pt confused earlier, combative, wants to leave AMA." At 11:00 pm Physician A noted Patient 5 was "confused but more relaxed." The hospital "Multidisciplinary Progress Notes" and "Shift Assessments" of 9/29/11 make no reference to such behaviors.

In interview on 5/16/12 at 1:20 pm the Chief Nursing Officer acknowledged that staff had failed to maintain an accurate and complete medical record for Patient 5 and had failed to implement hospital policy "Nursing Documentation Standards."